Approach to scrotal swelling

Question 1

You have been called to examine a valuable Warmblood stallion which has developed signs of acute abdominal pain. The owner has also noted a unilateral left scrotal swelling.

What are the differentials for acute abdominal pain and scrotal swelling in the stallion?

Answer 1

–Colic

–Scrotalitis

–Inguinal hernia

–Scrotal hernia

–Strangulating hernia

–360 testicular torsion

Question 2

Outline the key points of your history and physical examination to help differentiate between different conditions and triage this case.?

Answer 2

–U/S Scorotsal sacs

–Rectal palpate

–Palpate testes

–Palpates scrotal sac

Question 3

• On physical examination, the scrotal swelling is firm, painful and non-reducible.
• The horse has reduced gut sounds in all 4 quadrants and shows continuous moderate abdominal pain throughout your examination.
• Heart rate is 60bpm, resp rate is 40bpm, mucous membranes are dark pink with a capillary refill time of 2.5 seconds

What are your differentials now?

Is this likely to be a strangulating or non-strangulating intestinal lesion?

Answer 3

Likely to be strangulating due to GI Signs

Question 4

• Inguinal or scrotal hernia should be one of your differentials
• There are various different descriptions depending on whether the intestinal tissue is within or outside the vaginal tunic, and whether the vaginal tunic is intact (inguinal hernia, inguinal rupture, ruptured inguinal hernia)
• More importantly, you need to establish whether this is a simple non-strangulating hernia, or a strangulating hernia.

How will these differ on clinical signs and palpation?

Answer 4

Non-strangulating hernias are reducible back into the abdomen, and the horse will not show signs of abdominal pain or cardiovascular compromise

Strangulating hernias are non-reducible, and will show clinical signs of intestinal strangulation (small intestinal distension +/- nasogastric reflux, cardiovascular compromise and hypovolaemia)

Question 5

These clinical signs can also be seen with a 360o testicular torsion (cardiovascular and gut changes can be from severe pain)

How will you differentiate between a strangulating hernia and a testicular torsion?

Clue: there are three key diagnostic tests that you need to do….

Answer 5

1. Palpation of both testes and scrotal sacs: epididimis should be located caudodorsally, and will be displaced with torsions

2. Rectal palpation: check for small intestinal distension and palpate both inguinal rings to identify gut passing into them (NB Stallions may have an increased risk of rectal tears – owner communication and good restraint is essential)

3. Ultrasonography of both testes and scrotal sacs:

–Determine if there is omental or intestinal tissue within the vaginal tunic or scrotal sac

–Evaluate the testes (both sides)

–Note: There may be a very small section of intestine or omentum entrapped, and therefore negative findings does not rule out a strangulation – follow the clinical signs…

–Testicular compromise will occur with both conditions (venous distension, enlargement of testes, reduced blood flow on Doppler ultrasound)

Question 6

In this case:

Palpation – enlarged left testis, epididymis in correct position

Rectal palpation – multiple loops of distended small intestine, taut intestinal band entering left inguinal ring

Ultrasound – venous distension and reduced blood flow within left testis, area of compressed tissue within dorsal scrotal region – not able to identify as intestine

What is your diagnosis?

Answer 6

Strangulating herniation

Question 7

This image is taken of the scrotal region in the anaesthetised stallion

• The findings are consistent with a strangulating hernia – rectal palpation is most important in this case.
• This horse requires emergency surgery to free and possibly resect the bowel, and to avoid further testicular damage
• What further tests would you do prior to anaesthesia and surgery (review your colic assessment notes)?

Answer 7

–Haematology

–Biochemistry

–Assess hydration

–NG tube

• You should pass a nasogastric tube to relieve any gastric distension
• You should also run some bloods (PCV and TP as a minimum) to assess hydration and determine fluid therapy

The horse had 5 litres of nasogastric reflux, and a PCV of 45%, total protein of 80g/dl

Question 8

Surgical treatment for strangulating hernia will involve?

Answer 8

–Ventral midline celiotomy to retract the bowel into the abdomen

–Resection of any compromised bowel

–Exploration of the inguinal region

–Removal of the affected testes

–Closure of the inguinal ring

Question 9

Case outcome

Answer 9

• This horse had a very small section of intestine entrapped, hence the problem identifying this on ultrasound
• The bowel was entrapped and compromised but did not require resection
• The left testes was compromised so was removed
• The left inguinal ring was closed (by suturing both the external and internal inguinal ring)

Question 10

Intra-operative appearance of affected testis. Note vascular compromise (blue discolouration, and vascular distension of pampiniform plexus) – this was removed at surgery.

The condition should be managed surgically and, although the exact surgical approach and procedure may vary, the aim is to?

Answer 10

relocate the herniated organs to the abdomen and to completely or partially close the inguinal canal(s) to prevent the condition from recurring.

Question 11

Discuss inguinal hernia surgery?

Answer 11

An incision can be made directly over a simple unilateral inguinal hernia and the contents of the hernial sac milked back into the abdomen. The sac may be twisted to empty it and the hernial ring extended if necessary. In a female dog, the hernial sac is then amputated at its neck but in males this is not possible because the inguinal canal contains the spermatic cord. Since castration is recommended (to prevent recurrence and because the condition may be heritable), the testes may be removed and the tunica vaginalis closed at the level of the internal inguinal ring. A scrotal ablation may also be performed if this tissue is compromised. If the testes are to be retained, the herniated organs are relocated to the abdomen as before and the hernial sac (which is the parietal tunica vaginalis) is partially closed with transfixing sutures.

Question 12

What should you do surgery wise for a strangulated hernia?

Answer 12

If an area of intestine is strangulated, this should be resected and an anastomosis created between the oral and aboral portions. It is advisable to move the affected section of intestine into the abdominal cavity (by enlarging the hernial ring) before attempting this.